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1 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at or by calling Important Questions Answers Why this Matters: What is the overall deductible? $300 per student Does not apply to services at the Student Health Center, In- Preventive Care services, Office Visits with a set-dollar copayment or Prescription Drugs. The deductible applies to both In- and Non- services, combined. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your Benefit Booklet to see when the deductible starts over. See the chart starting on page 4 for how much you pay for covered services after you meet the deductible. Are there other Deductibles for specific services? Yes, a $500 for Additional deductible for non-anthem Blue Cross PPO hospital or residential treatment center or ambulatory surgical center if utilization review not obtained. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 1 of 15

2 Important Questions Answers Why this Matters: Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Yes, In- per student: $3,000 Non- per Student: $6,000 Balance-Billed Charges, the deductible, Health Care This Plan Doesn't Cover, Premiums, copayments, Additional deductibles. No. This policy has no overall annual limit on the amount it will pay. Yes, but you must seek care at the Student Health Center first. See or call for a list of In- s. Yes, you need written referral from the Student Health Center to see a specialist. There may be some providers or services for which referrals are not required. Please see the Benefit Booklet of coverage for details. The out-of-pocket limit is the most you could pay in coinsurance during a coverage period (usually 12 months) for your share of the cost of covered services. This limit helps you plan for health care expenses. In- and Non- out of pocket limits are not combined They accumulate separately. Even though you pay these expenses, they don t count toward the out of pocket limit. The chart starting on page 3 describes any limits on what the plan will pay for specific covered services. You must begin all of your care at the Student Health Center, except in case of emergency. They will provide a referral for care outside of the Student Health Center if necessary. If you use an In- doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your In- doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 4 for how this plan pays different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services, but only if you have the Student Health Center referral to see the specialist. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 2 of 15

3 Important Questions Answers Why this Matters: Are there services this plan doesn t cover? Yes. Some of the services this plan doesn t cover are listed on page 11. See your Benefit Booklet for additional information about excluded services. Glossary Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percentage of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 10% would be $100. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use an In- by charging you lower deductibles, copayments and coinsurance amounts. A Referral is a written authorization given by the Student Health Center to seek care outside of the Student Health Center for medically necessary care. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 3 of 15

4 Common Medical Event If you visit a health care provider s office or clinic Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit You Use a In- $15 Copayment /Visit $30 Copayment /Visit Chiropractor $30 Copayment per visit Acupuncture $30 Copayment per visit You Use a Non- Limitations & Exceptions The insured student must obtain any non-emergency medical care from the Student Health Center. The insured student must obtain a referral from the Student Health Center prior to seeking care with a specialist. Chiropractor A referral is required from the Student Health Center prior to seeking care with a chiropractor. Acupuncturist Coverage is limited to a total of 20 visits, In- s and Non- s combined per year Benefit Year. A referral is required from Student Health Center prior to seeking care from an acupuncturist. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 4 of 15

5 Common Medical Event If you have a test Services You May Need Preventive Care/Cancer screening/ *immunizations/well-woman and contraceptive care Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) You Use a In- No Charge You Use a Non- Limitations & Exceptions *Services are to be provided at the Student Health Center unless the student receives a SHC referral. The following partial list of immunizations are covered at 100%: Diphtheria, Tetanus, Pertussis, Measles, Mumps, Rubella, Varicella, Influenza, Hepatitis A, Hepatitis B, Pneumococcal, Meningococcal, Polio, and Human Papillomavirus (HPV). All other immunizations are covered at 90% In- and 60% Non- s. A referral from the Student Health 10% Coinsurance for Lab and X-Ray for Lab and X-Ray 10% Coinsurance A referral from the Student Health If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 5 of 15

6 Common Medical Event Services You May Need You Use a In- You Use a Non- Limitations & Exceptions If you need drugs to treat your illness or condition Generic drugs $10 Copayment (SHC or retail) $10+any amount over the contracted rate Covers up to a 30 day supply More information about prescription drug coverage is available at Preferred brand drugs $35 Copayment (SHC or retail) $35+ any amount over the contracted rate Covers up to a 30 day supply Non-preferred brand drugs $50 Copayment (SHC or retail) $50+ any amount over the contracted rate Covers up to a 30 day supply If you have outpatient surgery Facility (e.g., ambulatory surgery center) Physician/surgeon 10% Coinsurance A referral from the Student Health 10% Coinsurance A referral from the Student Health If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 6 of 15

7 Common Medical Event Services You May Need Emergency room services You Use a In- $100 Copayment You Use a Non- $100 + anything above the allowed amount. Limitations & Exceptions Copayment is waived if admitted inpatient. This is for the hospital/facility charge only. If you need immediate medical attention If you have a hospital stay Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon 10% Coinsurance for ground ambulance/no charge for air ambulance $50 Copayment /Visit 10% Coinsurance for ground ambulance/no charge for air ambulance 10% Coinsurance 10% Coinsurance The percentage of coverage is based on billed charges Costs may vary by site of service. You should refer to your Benefit Booklet for details. Failure to obtain preauthorization may result in non-coverage or an additional $500 deductible for Non-participating providers, waived for emergency admissions. A referral is required from the Student Health Center for non-emergency care. A referral from the Student Health Center is required If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 7 of 15

8 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Mental/Behavioral health Office Visits and outpatient services Mental/Behavioral health services during a hospital stay Substance use disorder Office Visits and outpatient services Substance use disorder services during a hospital stay Prenatal and postnatal care You Use a In- $15 Copayment per visit for Office 10% coinsurance for Facility You Use a Non- for Office Visit and Facility 10% Coinsurance $15 Copayment per visit for Office 10% coinsurance for Facility for Office Visit and Facility 10% Coinsurance $15 Copayment for initial visit only. All other visits have no charge. Limitations & Exceptions A referral from the Student Health This is for facility professional services only. Please refer to hospital stay for facility fee coverage. A referral from the Student Health Center is required, except in an emergency. A referral from the Student Health This is for facility professional services only. Please refer to hospital stay for facility fee coverage. A referral from the Student Health A referral from the Student Health If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 8 of 15

9 Common Medical Event If you need help recovering or have other special health needs Services You May Need You Use a In- You Use a Non- Limitations & Exceptions Delivery and all hospital services related to delivery 10% Coinsurance A referral from the Student Health Home health care No charge A referral from the Student Health Rehabilitation services $20 Copayment A referral from the Student Health per visit Habilitation services $20 Copayment A referral from the Student Health per visit Skilled nursing care 10% Coinsurance A referral from the Student Health Durable medical equipment 10% Coinsurance A referral from the Student Health Hospice service 10% Coinsurance A referral from the Student Health If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 9 of 15

11 If you lose coverage under the plan, you may be eligible for Conversion to an Anthem Blue Cross Individual plan. The premium may be significantly higher than the premium you pay while covered under this plan and the benefit plan design will be different. For more information on your rights to continue coverage, contact the plan at You can review instructions for enrolling in an Anthem Blue Cross Individual Conversion plan at click on your campus in the left navigation bar, then click on Medical Services under Online Services, and scroll down to Conversion Enrollment Information. Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem BlueCross ATTN: Appeals P.O. Box 4310 Woodland Hills, CA If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 11 of 15

12 Language Access Services: To see examples of how this plan might cover costs for a sample medical situation, see the next page. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 12 of 15

13 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6960 Patient pays $580 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductible $200 Copayment $60 Coinsurance $320 Limits or exclusions 0 Total $580 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4690 Patient pays $710 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductible $200 Copayment $330 Coinsurance $180 Limits or exclusions $0 Total $710 If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 13 of 15

14 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any student covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from In- providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, Copayment, and Coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. the plan provides. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 14 of 15

15 Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as Copayment, deductibles, and Coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. If you aren t clear about any of the underlined terms used in this form, see the Glossary (pg.3). You can view the Glossary Page 15 of 15

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet twww.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

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Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This is only a

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Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Only Plan Type: PPO This is only

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J3A59 National Guardian Life Insurance Company This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com

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Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual

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HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: HMO This is only

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